Finding into death of Stephen Ross Stronach

57y · Male·Pneumonia with contributing factors of epilepsy and congestive cardiac failure due to tetralogy of Fallot (repaired)

Stephen Ross Stronach, a 57-year-old man with intellectual disability living in specialist disability accommodation, died of pneumonia with contributing factors of epilepsy and congestive cardiac failure secondary to repaired tetralogy of Fallot. He presented to his GP on 5 February 2025 with lethargy and was appropriately referred to hospital where pneumonia and fluid overload were identified and treated with IV antibiotics. He experienced seizures and abdominal distention requiring investigation and intervention. The coroner found no evidence of clinical mismanagement by disability service providers or hospital staff. The death resulted from natural causes in a patient with complex comorbidities. This case emphasises appropriate recognition of deterioration in vulnerable populations and timely escalation to appropriate care.